Early results of combined carotid endarterectomy and coronary artery bypass grafting in patients with severe coronary and carotid artery disease

The management of patients with carotid artery disease who require coronary artery bypass grafting (CABG) remains controversial. Several published series from the USA (including one with prospective randomization) advocate a combined approach of carotid endarterectomy (CEA) followed immediately by coronary artery bypass surgery. However, experience of combined carotid endarterectomy and coronary bypass grafting has not been previously reported by a centre from the United Kingdom. Between 1986 and 1991 we performed this combined procedure on 18 patients who required myocardial revascularization and had co-existing severe (> 70%) carotid stenosis. Sixteen patients (89%) had angina and 11 patients (61%) had symptomatic carotid artery disease. The perioperative mortality was 5.5% and the ipsilateral perioperative stroke rate was 5.5%. These early results are encouraging and suggest that further evaluation of combined carotid endarterectomy and coronary artery bypass surgery is warranted.     

A surgical approach to coexistent coronary and carotid artery disease

OBJECTIVE: To assess the early results of combined coronary artery bypass graft surgery and carotid endarterectomy. DESIGN: Retrospective and ongoing analysis of patients who underwent combined coronary artery bypass graft surgery and carotid endarterectomy. SETTING: Cardiothoracic unit in a London teaching hospital. PATIENTS: From June 1987 to March 1995, 64 patients were identified. They were patients who were scheduled to have coronary artery bypass graft surgery or required urgent coronary revascularisation and who were found to have significant coexistent carotid disease. (Unilateral carotid stenosis > 70%, bilateral carotid stenosis > 50%, or unilateral carotid stenosis > 50% with contralateral occlusion.) INTERVENTIONS: Both procedures were performed during one anaesthesia: the carotid endarterectomy was performed first without cardiopulmonary bypass. After completion of carotid endarterectomy, coronary artery bypass graft surgery was performed. MAIN OUTCOME MEASURES: The incidence of stroke, transient ischaemic attack, and myocardial infarction in the early postoperative period was analysed. RESULTS: Myocardial revascularisation was successful in all 64 patients. There were no perioperative infarcts. In three patients (4.7%) a new neurological deficit developed postoperatively: two recovered fully before hospital discharge. CONCLUSIONS: Combined coronary artery bypass graft surgery and carotid endarterectomy were performed safely and with good results.     

Asymptomatic severe carotid stenosis: immediate surgery or watchful waiting? A decision analysis

OBJECTIVE: To analyze, for patients with asymptomatic severe carotid stenosis, the risks and benefits of two strategies: (1) immediate prophylactic carotid endarterectomy (CEA), and (2) medical management followed by CEA only after a transient ischemic attack (TIA) or a minor stroke has occurred. DESIGN: A Markov-based decision analysis model that simulates and counts the possible clinical outcomes (deaths, TIAs, and major strokes) of the two strategies. Data were drawn from the current literature. SUBJECTS: A hypothetical cohort of asymptomatic patients with severe (> 75% diameter reduction) carotid stenosis identified by noninvasive diagnostic tests. MAIN RESULTS: Given the immediate surgery-related risks, patients with a stroke incidence without preceding TIA of 3% per year will benefit from prophylactic CEA only if they survive more than 4 years after the procedure, whereas those with a higher stroke incidence (5% per year) will benefit from prophylactic CEA after just 2 years. However, the gain yielded by prophylactic CEA remains small. As age- or cardiovascular-related mortality increases, the maximum tolerated combined surgical mortality and morbidity rate below which prophylactic CEA yields an improved 5-year stroke- and surgery-related-event-free survival decreases--from 5% for patients aged 55 years to 2% for patients aged 85 years with a stroke incidence of 3% per year, and from 8.5% for patients aged 55 years to 4% for patients aged 85 years with a stroke incidence of 5% per year. On the other hand, for risk-intolerant patients who value the 2-year stroke- and surgery-related-event-free survival more than life in the distant future, the combined surgical morbidity and mortality rate below which prophylactic CEA remains the preferred strategy is below 3% at any age. CONCLUSION: Risk-intolerant patients should not undergo prophylactic CEA. On the other hand, for risk-tolerant patients willing to accept an immediate and dangerous procedure to decrease the future risk of death or chronic disability due to stroke, assessment of both perioperative risk and the risk of premature death from coexistent coronary artery disease should guide individual therapeutic decision-making.     

Prospective study of carotid endarterectomy and contralateral carotid occlusion

A total of 700 patients who had carotid endarterectomy (CEA) in the UK and Ireland during a 6-month interval between March and August 1994 were studied prospectively. Some 108 patients (15.4 per cent) had a contralateral internal carotid artery occlusion. Previous reports have shown an associated stroke rate of about 10 per cent in these patients. This study assessed complications and outcome for patients undergoing CEA with contralateral internal carotid artery occlusion compared with those without. The indications for surgery were comparable between the two groups although the patients with occlusion had a slightly higher incidence of arrhythmia and stroke. Intraoperative shunts were used in a significantly higher proportion of those with occlusion (83.3 versus 64.7 per cent, P = 0.0001). The combined death and stroke rate for patients with occlusion was 5.6 per cent compared with 2.4 per cent for the remainder (P not significant). On the basis of the present data, CEA with a contralateral carotid artery occlusion carries only a slight increase in the rate of postoperative stroke and death. This increase was not statistically significant and is lower than that reported previously.     

Elective stenting of carotid artery stenosis in patients with severe coronary artery disease

AIMS: To evaluate the feasibility and safety of elective carotid stent implantation in patients with carotid stenoses and concomitant coronary artery disease, as an alternative to combined carotid and coronary surgery. METHODS: We treated 50 patients with >70%, stenoses in 53 carotid arteries with balloon angioplasty followed by elective stent implantation. All patients had severe coronary artery disease, and/or mitral insufficiency, aortic stenosis, rhythm disorders or generalized arteriosclerosis. In three patients the opposite carotid artery was occluded; nine patients had bilateral stenoses of which two received stents bilaterally. RESULTS: Fifty-six successful stent implantations (42 Wallstents, eight BeStents, two AVE-Microstents, one Palmaz Schatz stent, three Sito stents) were performed, reducing the baseline percent stenosis from 78 +/- 18%, to 13 +/- 11%. Complications included three transient ischaemic attacks, one minor and one major stroke. Follow-up was available for 46 patients over a mean of 10 months. Three asymptomatic restenoses and one deformation of a BeStent occurred. CONCLUSION: Our preliminary results indicate that carotid artery stenting in patients with concomitant severe coronary artery disease is feasible, safe, and may be an alternative to combined carotid and coronary surgery.     

Coronary artery bypass grafting in patients with cerebrovascular disease

The incidence of carotid artery disease in patients undergoing coronary artery bypass grafting appears to be increasing as our population ages. The optimal treatment for these high-risk patients with concomitant carotid and coronary artery disease remains controversial. This review focuses on the management of patients with coexistent carotid and coronary arteriosclerosis. The significance and management of the patient with an asymptomatic carotid stenosis in patients undergoing coronary artery bypass grafting and the role of combined coronary artery bypass grafting and carotid endarterectomy in these patients will be discussed.     

Oculoplethysmography. Evaluation of patients with transient ischemic attacks from internal carotid artery disease

Oculoplethysmography was used to evaluate 66 patients with transient ischemic attacks prior to cerebral angiography. Fifty-eight (87.9%) symptomatic internal carotid arteries had anatomically significant stenosis. Only 69 per cent of these 58 arteries had positive OPG test. Thirty-one per cent of the arteries were well compensated hemodynamically with collaterals and had a false negative test. A negative OPG test does not rule out an anatomically significant internal carotid artery stenosis.     

Indications for carotid endarterectomy in patients with symptoms: when, where?

Carotid endarterectomy (CEA) is one of the most commonly used surgical methods in the treatment of cerebral stroke with both therapeutic and also prophylactic implications. CEA has been used in surgical practice for 40 years. At the beginning it was very popular and was widely used. Later, the opposite extreme was reached, and its therapeutic efficacy was denied unjustifiably. However, at the beginning of the ninetieth three large controlled studies were completed (North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial and Veterans Administrations Symptomatic Trial) and the results of these trials were the basis for establishing the solid criteria for the surgical procedure in some groups of symptomatic patients with stenosis of the internal carotid artery. Thus, CEA was in again. In accordance with the attitudes of the American Association Ad Hoc Committee (1995), evidenced indications for CEA in patients with symptomatic stenosis of the internal carotid artery (in the group with surgical risk less than 6%) include (a) single or recurrent episodes of TIA in the last 6 months, "crescendo" TIA combined with carotid stenosis > 70% with or without plaque ulceration, with or without antiplatelet therapy, and (b) mild stroke in last 6 months with carotid stenosis > 70% with or without plaque ulceration, with or without antiplatelet therapy. The authors report their experience and results of a six-month pilot study of 301 patients, of whom 248 were operated on for symptomatic carotid stenosis with low combined perioperative morbidity and mortality (0.6%). Also, indications for surgical reconstruction of carotid and coronary arteries in patients with marked signs of atherosclerosis in both arterial systems are discussed.     

Extrathoracic bypass procedures for proximal common carotid artery lesions

During a 10-year period ending in December 1991, 31 extrathoracic bypass procedures were performed in 29 patients for proximal common carotid artery atherosclerotic stenosis or occlusion. This included 16 men and 13 women, with a mean age of 63 years. Indications for surgery included transient ischemic attacks in 23 patients (79%), nonfocal symptoms in 4 patients (14%), and asymptomatic proximal common carotid artery stenosis associated with near-total occlusion of the internal carotid artery in 2 patients (7%). Severe proximal stenosis or complete occlusion of the common carotid artery was demonstrated angiographically in all cases. Subclavian-to-carotid bypass was performed in 26 cases and carotid-to-carotid bypass in 5 cases. Seventy-four percent of the bypass procedures were to the common carotid artery and 26% to the external carotid artery. Endarterectomy of the common carotid bifurcation was performed in conjunction with the bypass procedure in 13 cases and vertebral artery transposition in 2 other cases. Saphenous vein was used as the bypass conduit in 65% and prosthetic grafts in 35% of cases. There were no perioperative strokes or deaths in this series, and the mean postoperative hospital stay was 5 days. Follow-up ranged from 2 to 118 months (mean: 38.4 months). Graft occlusion occurred in two cases during the follow-up period (3-year patency rate: 90%), with recurrence of symptoms in one patient, which necessitated revision. Three patients had persistence or recurrence of symptoms despite patency of the graft, one other patient sustained a posterior circulation infarct, and there was one death unrelated to carotid vascular disease during the follow-up period. This experience shows that extrathoracic bypass procedures are safe and well tolerated for symptomatic proximal common carotid artery stenosis or occlusion. This method of reconstruction has excellent long-term patency and protection against further anterior circulation neurologic events.     

Extensive endarterectomy of the left anterior descending coronary artery combined with coronary artery bypass grafting

BACKGROUND: Complete revascularization of a diffusely diseased left anterior descending (LAD) coronary artery can be accomplished by extensive endarterectomy in conjunction with coronary artery bypass grafting (CABG). The present study was designed to assess the safety of the procedure, and which techniques lead to the best short- and long-term results. METHODS: Between January 1990 and October 1994 106 patients underwent extensive open endarterectomy of the LAD coronary artery combined with CABG at our institution. This group constituted 4.9% of all patients undergoing CABG during this period. The mean age of those studied was 64.4 +/- 9.2 years and 92% were male. In 22 patients (21%) the procedure was a repeat CABG and 12% had had percutaneous transluminal coronary angioplasty prior to the operation. Ninety-one per cent of the patients were in Canadian Cardiovascular Society (CCS) angina class 3 or 4, 91% had three-vessel disease and 36% had unstable angina at the time of surgery. The mean preoperative left ventricular ejection fraction was 53.6 +/- 14.9% (range, 15-80%). The internal mammary artery (IMA) was used to bypass the LAD coronary artery in 40 patients (38%) and a saphenous vein graft (SVG) was used in 66 patients. In 25 of the IMA bypass group an additional venous patch was used (IMA+P). RESULTS: The overall mortality rate was 9.4% (10 patients), including seven immediate postoperative deaths. When the IMA was used as a conduit the mortality rate was only 5.0%. There were seven (6.6%) postoperative non-fatal myocardial infarctions. There was a low incidence of other postoperative complications, similar to that following CABG without endarterectomy performed during the same period. Multivariate analysis identified emergency operation, two-vessel endarterectomy and female sex as independent risk factors for mortality. Upon follow-up study of 94 hospital survivors (98%), at a mean of 26.5 months (range, 1-48 months), all endarterectomy patients were in CCS class 1 or 2. Seventy-eight patients (83%) had an excellent postoperative exercise tolerance and the left ventricular function was preserved. The 4-year survival rates were 88% and 96% and the cardiac event-free survival rates were 74% and 87% in the SVG and IMA groups respectively. CONCLUSIONS: Complete revascularization of the diffusely diseased LAD coronary artery can be accomplished by adjunctive open endarterectomy with a degree of operative risk (mortality 9% and incidence of non-fatal myocardial infarction 7%). The immediate and medium-term results are improved when the IMA is used as a conduit, with or without additional venous patch. Independent risk factors for mortality were two-vessel endarterectomy, female sex and emergency operation. The long-term results revealed an overall survival rate of 92% and a cardiac event-free survival rate of 79% at 4 years, as well as excellent functional results.     

Indication for surgery of asymptomatic carotid lesions

The incidence of cerebrovascular diseases with transient or persistent neurologic dysfunction has increased significantly. Although patients with symptomatic carotid artery stenosis clearly benefit from operative therapy, the indication to prophylactic surgery of asymptomatic carotid lesions however is still controversial. Based on data from a recently completed prospective randomized study and on analysis of the literature the indication and results of surgical treatment of asymptomatic stenoses of the carotid arteries are discussed. From 1970 to 1990 a total of 744 uni-or bilateral reconstructions of the internal carotid artery were performed in 631 patients. The perioperative morbidity (permanent neurologic deficiency) and mortality was 1.1% (n = 8) resp. 0.8% (n = 6). During the follow up period up to 18 years another 9 patients suffered from stroke (1.2%). The annual stroke incidence amounted to 0.2%. An important prerequisite for surgery is the so called critical internal carotid artery stenosis, implying reduced cerebral vasomotor reactivity or high embolic risk of an ulcerative plaque. Proper selection of patients (exclusion of multiple concomitant diseases) and an experienced team of vascular surgeons with operative morbidity and mortality below 1-2% validates surgical treatment of asymptomatic carotid artery stenoses.     

The natural history of asymptomatic carotid artery disease

PURPOSE: The purpose of this article is to determine the natural history of carotid artery disease among asymptomatic patients with cervical bruits or other risk factors for stroke and to study the value of duplex ultrasonography in predicting future neurologic events. METHODS: Two hundred forty-two asymptomatic, unoperated patients, referred for evaluation of asymptomatic carotid artery disease, were followed prospectively with duplex ultrasonography. RESULTS: Fifteen ischemic strokes (6.2%) and 20 transient ischemic attacks (TIA) (8.3%) occurred in 34 patients during a mean follow-up of 27.4 months. Annual stroke, TIA, and combined event rates were 2.7%, 3.6%, and 6.2%, respectively. Although patients with 80% to 99% lesions had a 20.6% annual event rate, most events occurred contralateral to these lesions; the vessel-specific annual event rate for 80% to 99% disease was 5.1%. Only one of 15 strokes occurred ipsilateral to an 80% to 99% stenosis. Echolucent plaques were associated with TIA and stroke (5.7% annual vessel event rate vs 2.4% for echogenic plaques, p = 0.03). Disease progression was highly correlated with TIA and stroke (p < 0.0001), but it usually occurred in association with rather than before ischemic events, thus proving more useful in explaining pathogenesis than in predicting future events. There was no association between aspirin use and TIA, but patients taking aspirin had a threefold higher annual stroke rate (1.6% vs 4.8%, p = 0.027). CONCLUSIONS: This study, while confirming significant risk for asymptomatic patients with critical stenosis or echolucent plaque, demonstrates the importance of contralateral disease and the absence of orderly progression from minimal disease through high-grade stenosis to symptomatic cerebral ischemia. TIA and stroke commonly occur in association with abrupt, unpredictable, quantum changes in carotid artery disease.     

Surgical treatment of common carotid artery occlusion

Eight patients with common carotid artery (CCA) occlusion underwent bypass with saphenous vein to either the carotid bifurcation (five), the internal carotid artery (two), or the external carotid artery (one). Indications included ipsilateral transient ischemic attack (two), recent nondisabling hemispheric stroke (two), and transient nonhemispheric cerebral symptoms (two). Two asymptomatic patients with CCA occlusion and contralateral internal carotid stenosis underwent prophylactic revascularization prior to planned aortic surgery. There were no perioperative strokes, occlusions, or deaths. Late ipsilateral stroke occurred in two patients, and one patient had a single transient ischemic attack after 2 years. The four patients with preoperative transient cerebral ischemia experienced relief of their symptoms. Duplex ultrasound is an accurate screening modality for distal patency. Collateral filling of the internal or external carotid artery can usually be demonstrated after aortic arch or retrograde brachial contrast injection. End-to-end distal anastomosis after endarterectomy eliminates the original occlusive plaque as a potential source of emboli. The subclavian artery is preferred for inflow on the left. The CCA origin is easily accessible for inflow on the right. Bypass of the occluded CCA is safe and may be effective in relieving transient cerebral ischemic symptoms, although long-term ipsilateral neurologic sequelae may still occur.     

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from gastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.     

Shortening and reimplantation for tortuous internal carotid arteries

PURPOSE: The purpose of this study was to assess the outcome after the shortening and reimplantation of tortuous internal carotid arteries to prevent kinking after endarterectomy. METHODS: Through a review of prospective records, we studied patients who underwent carotid endarterectomy (CEA) (n = 233) between 1993 and 1996 who had symptomatic stenosis of the internal carotid artery (ICA) of more than 70%. An elongated proximal ICA was excised, and the ICA was reimplanted into the bifurcation in 30 (13%) patients, with additional patch angioplasty in 5 patients. Of the remaining 203 patients, 50 (21%) had Dacron patch angioplasty, and the rest had conventional CEA with simple closure. RESULTS: In the reimplanted group, one patient had a minor stroke with complete recovery on discharge. Three patients (10%) had neck hematomas requiring reexploration, but in none of these was the bleeding from the artery. At mean follow-up of 15 months, 93% of the arteries were widely patent. Significant stenosis secondary to neointimal hyperplasia was detected in only two patients, for a restenosis rate of 6.7%, which is in line with other published reports. In the control group, 8 (3.9%) patients had perioperative transient ischemic attacks, 5 (2.5%) had strokes, and 13 (6.4%) had hematomas requiring evacuation. At follow-up, 14 (6.9%) of the arteries had restenosed. CONCLUSION: In carotid surgery, reconstructive techniques must be tailored to operative findings. Excision of a tortuous elongated proximal ICA with reimplantation is not associated with additional mortality or morbidity rates over those of conventional CEA alone and has the advantage of removing disease at the bifurcation. This procedure was carried out in 13% of our patients and should be a procedure with which the vascular surgeon is familiar.     

Continuous retrograde cardiac perfusion decreases risk of reoperative coronary artery bypass grafting

Embolization of atheromatous debris from old saphenous vein grafts is a major factor that increases the risk of reoperative coronary artery bypass grafting (CABG) when compared with primary CABG. To decrease this risk, a technique consisting of minimal dissection of the heart prior to cross clamping, continuous retrograde coronary sinus perfusion with 32 degrees C blood, and temporary posterior cardiac interventricular vein occlusion, during which time all dissection and anastomoses are performed, was evaluated prospectively in 130 consecutive patients from January 2, 1991, through February 28, 1995. This group was compared with a cohort of 1107 patients undergoing primary CABG performed concurrently. The two groups were similar in age (median sixty-eight years), incidence of hypercholesterolemia, peripheral vascular disease, smoking history, and left main stem stenosis. More patients undergoing reoperative CABG had previous myocardial infarctions (61.5% vs 54.5%), a higher incidence of triple-vessel coronary artery disease (89.2% vs 77.1%, P = 0.002), and a lower ejection fraction (54.0% vs 56.9%). The median interval from primary CABG to reoperative CABG was one hundred twenty-seven months with a range of 2.5 to two hundred seventy-nine months. The cross clamp time (median one hundred three vs sixty-nine minutes, P = 0.000001) and perfusion time (median one hundred thirty-four vs ninety-four minutes, P = 0.000001) were significantly higher in the reoperative CABG group. The requirements for inotropic support postoperatively, perioperative myocardial infarction (1.5% vs 2.4%, P = 0.397), and mortality (3.1% vs 3.4%, P = 0.54) were statistically equivalent in the two groups. These data reveal that continuous retrograde coronary sinus perfusion, posterior cardiac interventricular vein occlusion, and single cross-clamping technique improve outcomes of reoperative CABG to that approaching primary CABG.     

Diagnosis of carotid artery stenosis: comparison of oculoplethysmography and Doppler supraorbital examination

Both Doppler supraorbital examination (OSM) and oculoplethysmography (OPG) were administered to 101 patients (202 arteries) to document the presence or absence of hemodynamically significant lesions of the internal carotid artery prior to angiography. There was no significant difference between the OSM and OPG with respect to diagnostic sensitivity or specificity, incidence of false-negative or false-positive results, and overall diagnostic accuracy. The diagnostic accuracy for the OSM and the OPG were 94.2% and 91.6%, respectively. In 171/202 (84.6%) arteries, the OSM and OPG were in diagnostic agreement, and the overall diagnostic accuracy of the combined tests was 97%. However, when the OSM and OPG did not agree (31/202 arteries, 15.4%), the diagnostic accuracy of neither the OSM nor the OPG was acceptable. Although the best diagnostic accuracy was obtained using two means of noninvasive cerebrovascular testing, in those instances where only one test may be available, the OPG would appear to be the test of choice. In those laboratories in which high diagnostic accuracy is obtained with the OSM, the addition of OPG testing will increase the overall diagnostic accuracy to a very high level. The presence of a midcervical bruit was found to have a very poor correlation with the incidence of hemodynamically significant stenoses of the internal carotid artery. Although both the OSM and OPG have minimal value in patients with symptomatic cerebrovascular disease, these tests play a very important role in screening patients for asymptomatic carotid stenosis or atypical cerebrovascular symptoms.     

Open heart surgery in adults at Ramathibodi Hospital

Two hundred and thirty consecutive adult patients underwent open heart surgery at Ramathibodi Hospital from January 1, 1994 to December 31, 1995. The patients were categorised into 4 groups, A, B, C and D; consisting of 52 (22.4%) with adult congenital heart disease, 121 (52.2%) with acquired valvular heart disease 52 (22.4%) with coronary heart disease and 7 (3%) with diseases of the aorta. The mortality in various groups were analyzed separately each year, in 1994 and 1995. The overall mortality, in adult congenital heart disease, was 5.7 per cent consisting of acquired valvular heart disease (6.6%), coronary artery disease (CAD) (3.8%) and diseases of the aorta (14.2%). We found that the incidence of CAD and the patients underwent CABG were increasing. The overall mortality for open heart surgery in adults was 6 per cent. Though the number of patients who underwent open heart surgery did not truly represent all heart diseases, trends of coronary artery disease seem to be increasing. Risk factors of coronary artery disease and low mortality from CABG might be the main reasons that CABG has increased obviously.     

Relationship between intraoperative color-flow duplex findings and early restenosis after carotid endarterectomy: a preliminary report

PURPOSE: This study was undertaken to examine the relationship between intraoperative color-flow duplex (CFD) findings and the development of restenosis in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-eight patients (43 male and 35 female; mean age, 65 years) underwent 86 CEAs (eight staged bilateral) and intraoperative CFD during a 31-month period. Three patients (three CEAs, 3%) underwent both CFD and a completion arteriographic scan. Patients were observed in a postoperative protocol using CFD surveillance. The follow-up interval ranged from 6 to 24 months (average, 12 months). RESULTS: After undergoing CEA, 10 patients (10 CEAs, 11%) had an abnormality detected by intraoperative CFD; one was confirmed with a completion arteriographic scan. These abnormalities consisted of elevated peak systolic velocities (PSV) with a mosaic color pattern suggesting turbulence seen in six CEAs, including one internal carotid artery (ICA) with abnormal hemodynamics and an unremarkable completion arteriogram. Intimal defects on B-mode were seen in another four CEAs. These carotid arteries were reexplored, defects (intimal flaps with platelet thrombus) were confirmed by direct examination, and all were repaired with or without a patch (six ICAs, three external carotid arteries, and one common carotid artery). No cerebrovascular events occurred in the perioperative period. No carotid restenosis (> or = 50% diameter reduction) was identified during follow-up of 43 patients (48 CEAs, 56%). Two patients had recurrent neurologic symptoms. CONCLUSION: Intraoperative CFD is an effective test for detecting flow abnormalities or intimal defects in patients undergoing CEA. Ensuring normal intraoperative hemodynamics after CEA may be a major factor associated with decreased incidence of perioperative cerebrovascular events and subsequent carotid artery restenosis.     

Carotid endarterectomy for asymptomatic carotid artery stenosis: patients with severe bilateral disease a high risk subgroup

Carotid endarterectomy if advised for asymptomatic disease must be associated with a low peri-operative morbidity and mortality and satisfactory long-term results. Over a 12 year period between 1978-1989 181 carotid endarterectomies were performed on 163 patients with asymptomatic carotid artery stenosis. There were 112 males and 51 females with a mean age of 64.9 years. All patients had a high-grade lesion (> 70% stenosis). The combined operative mortality and stroke rate was 2.8%. On long-term follow up six patients suffered a stroke. Only one patient however sustained a stroke in the same territory as the previously operated carotid artery. Four years following surgery 78% of patients were alive. Carotid restenosis or occlusion occurred in 8.3% of the remaining patients, all of whom were asymptomatic. All the immediate postoperative strokes occurred in patients with severe bilateral carotid artery disease. These patients with severe bilateral disease appear to constitute a high risk sub-group for peri-operative stroke. The role of 'normal pressure-hyperperfusion breakthrough' syndrome as the presumed aetiology of two of the postoperative cerebral haemorrhages is discussed.